HEALTH & DIET SURVEY
 
 
INTRODUCTION: We are studying attitudes about health and healthy eating. Your feedback will be anonymous and will help to shape the educational materials and healthy products that are made available to Americans. Please begin the survey now.
 
 
Please indicate whether you are concerned about any of these health problems. . . . (check all that apply)
Concerned for Myself I've Been Diagnosed With This Condition Concerned for a Family Member
Diabetes
Heart attack
Heart disease
High blood pressure
High cholesterol
Overweight
Peripheral Artery Disease
Stroke
 
 
 
Have any of your close relatives suffered from the health problems mentioned above? If yes, please indicate which relatives. (check all that apply)
 
None
 
Mother
 
Father
 
Brother
 
Sister
 
Grandparent
 
Son/Daughter
 
Don't Know

 
 
 
Do you wish you knew more about any of these health topics? (check all that apply)
 
exercise
 
healthy recipes
 
cholesterol control
 
oral care
 
proper diet
 
blood pressure control
 
none
 
Other
 

 
 
Now for some questions about eating habits....
 
 
What brand(s) of Probiotic Yogurts have you heard of, have you bought in the last 3 months, and which ones do you plan to buy next? (Please complete all 3 columns, marking any that apply)
Heard Of Bought in Past 3 Months Plan to Buy Next
Breyer’s Light
Dannon Activia
LaYogurt
Stonyfield Farms
Yoplait Yo-Plus
Store brand probiotic yogurt
Other
None/Don’t know
 
 
Which soups/broths have you bought in the last 6 months, which ones do you plan to buy next, and which ones do you buy most often? (Please complete all 3 columns, marking any that apply)
Bought in Past 6 Months Plan to Buy Next Buy Most Often
CANNED SOUPS
Don’t Use Canned Soups
Amy’s
Campbell’s Chunky
Campbell’s Condensed
Campbell's Healthy Request
Campbell’s Lower Sodium
Campbell’s Select Harvest
College Inn
Healthy Choice
Bought in Past 6 Months Plan to Buy Next Buy Most Often
Healthy Valley
Progresso
Swanson
V8 soup
Other canned soup
DRY SOUPS
Don’t Use Dry Soups
Campbell’s
Herb-Ox
Knorr
Bought in Past 6 Months Plan to Buy Next Buy Most Often
Lipton
Wyler’s
Other dry soup
OTHER SOUPS
Ramen noodles
Homemade soups
Other
 
 
 
Do you take an aspirin a day to prevent a heart attack?
 
Yes
 
No
 
 
Which brands of aspirin have you heard of, have you bought in the past 3 months, and which ones do you plan to buy next? (Please complete all 3 columns, marking any that apply)
Heard Of Bought in Past 3 Months Plan to Buy Next
Bayer
Ecotrin
Excedrin
St. Joseph's
Store Brand
None/Don't Know
Other
 
 
 
Are you currently taking prescription medications to control any of these? (check all that apply)
 
blood thinning
 
diabetes
 
heart rhythm
 
high blood pressure
 
high cholesterol
 
don't know/not sure
 
Other
 

 
Please contact survey@adialogue.com if you have any questions regarding this survey.
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